Laserfiche WebLink
20200037 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181263 1/22/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arca 6080 <br /> Business Site Address City ZIP Code <br /> 85 E Louise Lathrop 95330 <br /> It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# <br /> Matthew Campbell (925) 551-7555 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8716847 4/8/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications) <br /> OPW Tech Cert# 0165585 Exp. 10!3/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ©x Manufacturer Guidelines(Specify) <br /> Hydrostatic, OPW, Tape Measure <br /> ❑Industry Code or Engineering Standard(Specify) <br /> ❑Engineered Method(Specify) <br /> # <br /> Attach the testing procedures and all documentation required to determine the resells, of Attached Pages <br /> TANK ID:(By tank number,stored product,etc) 87 A Vapor T1 87 B Vapor T1 91 Vapor T2 <br /> Spill Container Manufacturer OPW OPW OPW <br /> Method of Cathodic Protection ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Speufy in v) ❑Other(Specify in V) ❑Other(Specify in v) ❑Other(speuty in v) <br /> Inside Diameter of Spill Container (Inches) 12 12 12 <br /> Depth of Spill Container (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? E]Yes ❑No 0 Yes ❑No I]Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty ❑Drain Valve <br /> ❑Drain Valve [j Drain Valve ❑Drain Valve <br /> (�]Onsite Pump ❑x Onsite Pump Q Onsile Pump ❑Onsite Pump <br /> ❑Other(Specifyin v) ❑Other(Specify in V) ❑Other(Specify in v) ❑Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Q Pass ❑Fail I Q Pass ❑Fail Q Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any iterns marked"Fail'*above must be explained to this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Cafitomia Errvironmental Reporting System.ID=Identfication.UST=Underground Storage Tank,[CC=tntemahenal CodeCo �mo�N M C NTAL HEALTH <br /> n7PA,P.Tn,Pr-NIT <br />